09/12/2012

1

AC Joint "Dislocations & Instability

������� ���!

Is the ACJ Important? !   YES – for overhead athletes:

!   Following ACJ Dislocations:

!   30% of overhead athletes had to reduce sport

!   9% had to change sport

!   Climbers and patients performing strength training had to reduce their activities or give up sports

!   Altered activities in overhead ball sports

Rangger et al. Orthopade 2002 Jun;31(6):587-90

Is the ACJ Important? !   YES – for high demand professions:

!   Following ACJ Injuries:

!   164 US Naval Cadets !   Residual symptoms found at 6 month follow-up:

!   36% of Grade 1

!   48% of Grade 2 !   Major in 13%

!   Minor in 35% !   69% of Grade 3

Cox. Am J Sports Med, 1981

09/12/2012

2

09/12/2012

3

Indications for Stabilisation !   Literature = Type 4, 5 & 6

Ceccarelli et al. 2008

!   “From the literature evaluation, clinical results seem to be comparable between the operative and the conservative treatments, "but complications are more evident in the surgery group. "

!   Since there is not a preponderance of positive papers showing the benefits of a surgical technique over conservative therapy, the nonoperative treatment is still considered a valid procedure in the grade III acromioclavicular separation.

!   More prospective randomized studies using validated outcome measures are needed to identify the suitable operation techniques for the acute injuries.”

09/12/2012

4

What are we trying to achieve?

•  “A pain free & stable shoulder "that has enough mobility, strength "& muscle control for a patient’s "desired level of activity & participation”

•  Peter Rheinlaender

My indications !   Patient Demands

!   Work demands

!   Society demands !   Overhead Athlete

Review 3 weeks

Approach Acute Injury < 1 week

Review"3 months Surgery

Coping Not Coping

09/12/2012

5

Surgical procedures

Coracoclavicular "Ligaments

!   Strength – 500N (+/- 134) !   Stiffness – 103N/mm (+/- 30)

!   Uniaxial Tension 25mm/min

Harris et. al. Am J Sports Med. 2000

Harris et al. AJSM 2000

•  “None of the reconstruction techniques analyzed in the present study were able to restore the normal mechanical function of the intact coracoclavicular ligament complex”

09/12/2012

6

ACJ Ligaments !   Two thirds of the superior stability

for lesser displacements

!   90% the posterior stability

Fukuda et al. JBJSA. 1986

Dynamic Stability !   Delto-trapezial fascia

Fukuda et al. JBJSA. 1986: Copeland & Kessel. Injury. 1980; DePalma. 1973; Urist. JBJS 1963.

Lizaur et al. JBJS. 1994

My Experience

2001 2008

09/12/2012

7

Revisions !!!

LARS Ligament (Corin)

!   Braided Polyethylenetraphthalate !   1500N tensile strength (30 LAC)

!   No reduction in mechanical resilience after over 10 million wear cycles loaded in torsion, traction and flexion [Fialka et al. 2005;

!   Vascularisation & Fibrous ingrowth - Collagen Type 1 [Trieb et al. Eur Surg Res. 2004; Yu et al. 2005; Pelletier & Durand]

09/12/2012

8

Standard repair

Shoulderdoc.co.uk

Modification 1

Shoulderdoc.co.uk

Modification 2

Shoulderdoc.co.uk

09/12/2012

9

Closure !   Repair the Superior AC Ligaments !   Repair the Delto-Trapezial Fascia

x-rays - "Day 1, 3 weeks, 3 months, 1yr, 2yrs

Shoulderdoc.co.uk Shoulderdoc.co.uk

Shoulderdoc.co.uk Shoulderdoc.co.uk

09/12/2012

10

!   Phase 1: (Level 1-2 Exercises) !   Core stability & Scapula control

!   Proprioceptive exercises (minimal weightbearing below 90 degrees)

!   Active ROM as comfortable !   Do not force or stretch !   No resistance exercises

!   Phase 2: (Level 2-3 Exercises) !   Progress to light resistance exercises as tolerated

!   Sports-specific rehabilitation - Plyometrics and pertubation training

!   Phase 3: (Level 3+ Exercises) !   Regain scapula & glenohumeral stability working for shoulder joint control

rather than range

!   Gradually Strengthen

POST-OP

THANK YOU

•  lenfunk@shoulderdoc.co.uk